Provider Demographics
NPI:1235559451
Name:SOM, SUMIT (MD)
Entity Type:Individual
Prefix:DR
First Name:SUMIT
Middle Name:
Last Name:SOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5134
Mailing Address - Fax:
Practice Address - Street 1:2051 CLEVIDENCE BLVD STE B
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-2278
Practice Address - Country:US
Practice Address - Phone:812-280-9145
Practice Address - Fax:812-280-6627
Is Sole Proprietor?:No
Enumeration Date:2014-04-27
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0062046207Q00000X
OK37067207Q00000X
IN01078882A2083P0901X
TXBP200585332083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100593410Medicaid